Barnstable County is providing integrated care for women with substance abuse or co-occurring disorders who are victims of violence, by expanding the capacity of the primary substance abuse treatment provider on Cape Cod, Gosnold, Inc., to offer outpatient substance abuse assessment on an outreach basis to 330 women receiving services from Independence House, and Safe Harbor, the two primary domestic violence and sexual assault agencies on Cape Cod. Of these 330 women, Project WAVE intends to provide outreach, engagement, integrated assessment, intervention, treatment, referral and care coordination services to 240 women and their children over the three years of the funding period. The Institute for Health and Recovery (IHR), which has been actively engaged in developing training, policies and protocols for integrating domestic violence, sexual assault, mental health and substance abuse services, has been contracted to administrate the grant and work in collaboration with both Gosnold and the domestic violence/sexual assault agencies. IHR is providing cross training for the staff of all three agencies, as well as supervision for three Gosnold clinicians who are the Family Care Coordinators (FCCs). IHR has trained the staff of the domestic violence and sexual assault agencies to screen women receiving their services for substance abuse using a modified version of the 5 Ps (Parents, Peers, Partner, Past, Present). Women who screen positively and desire WAVE services receive a complete substance abuse and co-occurring disorders assessment from an FCC, who works with the woman and the staff of the domestic violence/sexual assault agency to develop a service plan that addresses all identified issues. Should a woman need a level of care beyond outpatient, she will be referred to Gosnold for inpatient or residential treatment. Integrated individual and/or group substance abuse, co-occurring disorder and violence/ trauma counseling is provided on-site by the FCCs. In order to improve retention in services and reduce/ manage relapse, service enhancements are also offered from IHR's WELL Project, one of SAMHSA's Women, Co-Occurring Disorders and Violence study sites. These include Seeking Safety, a safety skill building group for substance abuse and trauma, Nurturing Families, a parenting relationship group for women as well as screening / referral services for their children, if needed, along with WELL Child, a children’s self-esteem and resiliency building group. Education related to substance abuse/ co-occurring disorders and their relationship to violence/ trauma is provided for women receiving domestic violence/sexual assault services during the three years to facilitate self-referral to substance abuse treatment. FCCs also provide case consultation, aftercare planning and technical assistance on policies and procedures to enhance the agencies' capacity to work with women with substance abuse and co-occurring disorders.
TARGET POPULATION
- Women seeking sexual assault and domestic violence services who may be using/ abusing substances to cope.
PROGRAM EFFECTIVENESS
- The first goal of Project WAVE is to provide substance abuse assessment and outreach for 330 women living in a rural community who are receiving domestic violence/ sexual assault services at Independence House and Safe Harbor. To date, Project WAVE has assessed and performed outreach to 280 women and engaged 156 women in some level of services during its first two years, exceeding its outreach/ engagement goals by 6% for that time frame.
- WAVE’s second goal is to provide women with skills to improve retention in treatment and reduce relapse. Of the 156 women enrolled, 143 have been retained in WAVE services.
- The third goal of the project is to increase resiliency in the children of the women who are victims of interpersonal violence and have substance abuse or co-occurring disorders. To date, 30 children have participated in the WELL Child group intervention and 15 of those have been assessed and referred for further evaluation.
Another important goal of Project WAVE is to enhance the capacity of the two domestic violence/ sexual assault agencies to identify, refer and support the recovery process for women seeking their services who are also dealing with substance use and/ or co-occurring disorders and to increase the capacity of Gosnold, Inc. to identify, refer and support the healing of women seeking their services for substance use and/ or co-occurring disorders who have had experiences of interpersonal violence.. The WAVE FCC staff regularly attends all staff meetings at all of the involved agencies, participates in integrated treatment planning and service coordination, co-facilitates the Seeking Safety, Nurturing Families and WELL Child group interventions with staff from the domestic violence/ sexual assault agencies in a train-the-trainer model. To date, 6 staff from Safe Harbor and 4 staff from Independence House have been trained in the facilitation of these group interventions. In addition, Project WAVE has sponsored numerous staff trainings addressing such topics as Motivational Interviewing, the Stages of Change, Implementing Seeking Safety and a series of trainings addressing the intersection and enmeshment of substance use, co-occurring disorders and experiences of trauma/ violence. Generally speaking, the overall value of these was rated 90% above average or excellent with overall knowledge gained rated at 80% above average or excellent.
UNIQUE ACCOMPLISHMENTS
As a targeted capacity expansion grant, Project WAVE’s major goal is to provide substance abuse and co-occurring disorder outreach and engagement in treatment to women who would not ordinarily receive such services. It is a unique collaboration to assist domestic violence agencies in identifying women in need of substance abuse assessment, counseling and other services. One of the most notable accomplishments of Project WAVE has been the shift within the domestic violence/ sexual assault agencies regarding their willingness to identify the impact of substance use disorders on the women they serve. Prior to WAVE, substance use disorders were perceived as a weapon that could be potentially used by the batterers against the women and were often not addressed. Since WAVE’s involvement, both agencies have come to recognize the power of substances as a coping tool that, in the past, may very well have helped the woman be safe and survive. This shift in perception has promoted an emphasis on safe versus unsafe choice-making thus encouraging women to identify and more fully utilize the strengths of their survivor selves in effecting the changes necessary to move forward in the recovery and healing process.
To date, 296 women have been assessed and outreached, with 174 women engaging in some level of care. All 174 women have been GPRA’d and 161 are participating in the local evaluation as well. WAVE’s retention rate is at 86% with 23 women or 14% dropping out of services and not responding to continued outreach. This drop-out rate is particularly notable given the reality that many of our women are actively fleeing abusive situations and that this is a population that generally exhibits a 50% attrition rate. To date WAVE’s 6-month GPRA (Government Performance and Results Act) follow-up rate is 79%.
Based on current information, the preliminary analyses of data indicate some significant change between baseline and 6 months. Some of these are:
- An increase in social connectedness.
- An increase in housing stability.
- A n increase in rates for both full and part time employment.
- An increase in the average job income.
- An increase in the average total income .
- A decrease in the rate of PTSD diagnosis based on the Foa Scale.
- A decrease in psychological distress based on the GSI.
- A shift in PTSD symptom severity ratings with a decrease in both the severe and moderate-to-severe categories.
- A decrease in legal involvement and negative consequences.
***The data on abstinence in the women served indicates a decrease in abstinence at the 6-month point, which is to be expected since these are women who were not initially seeking substance abuse services. Also, the stigma and shame inherent in both substance abuse and victimization, along with the fear of how the batterer could use this against her prevents women from disclosing substance use initially. Consequently, until trust is built in their relationships with the FCCs, women do not begin to get honest regarding their use of substances. It is expected that the rate of abstinence will increase at the 12 month point.
In responses to questions regarding consumer perception of care, the 6-month preliminary data indicated women agreed or strongly agreed that the FCCs demonstrated:
- 100% sensitivity to cultural/ ethnic background.
- 98% respect for client values and belief systems.
- 98% clear communication and sharing of information.
- 96% offering of skills to deal with violence and abuse.
- 96% treatment of client as a whole person rather than focusing on separate problems.
- 93% encouragement to access self-help groups.
- 91% education about the relationship between domestic violence and the use of alcohol and drugs.
Women who have been violently victimized carry an inherent sense of helplessness, powerlessness and hopelessness that creates a loss of a belief in their own ability to make safe choices and influence outcomes. Many of the women served by WAVE have had numerous experiences of rejection, abandonment and betrayal resulting in major trust issues. Utilizing the Relational Model of Women’s Psychology, Motivational Interviewing techniques and the Stages of Change, WAVE staff has been able to establish relationships with the women they serve that overcome these challenges allowing for supportive care coordination and follow-up for a full twelve months, if the woman so desires.
Project WAVE has overcome some unique challenges such as safety issues for women and their children fleeing domestic violence, including relocation in other communities to escape their batterer, as well as denial of the impact of substances on their ability to keep themselves and their children safe. Further women and their children who may wish to remain on Cape are often forced to move elsewhere due to the lack of year-round employment and affordable housing in a rural, resort community like Cape Cod.